- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $495.85 / $495.85 / $495.85
| Professional | | $495.85 | $495.85 | $495.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,459.00 / $2,358.00 / $2,830.00
| Professional | | $1,459.00 | $2,358.00 | $2,830.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $508.74 / $686.80 / $992.04
| Professional | | $508.74 | $686.80 | $992.04 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,607.00 / $2,607.00 / $10,877.00
| Facility | | $2,607.00 | $2,607.00 | $10,877.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $476.17 / $982.10 / $1,593.79
| Professional | | $476.17 | $982.10 | $1,593.79 |